Provider Demographics
NPI:1780638619
Name:BACKHAUS, SOUGANDHI (PHD)
Entity Type:Individual
Prefix:
First Name:SOUGANDHI
Middle Name:
Last Name:BACKHAUS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6804 WOOD HAVEN PL
Mailing Address - Street 2:
Mailing Address - City:ZIONSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46077-8560
Mailing Address - Country:US
Mailing Address - Phone:317-879-8940
Mailing Address - Fax:317-872-0914
Practice Address - Street 1:4141 SHORE DR
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254-2607
Practice Address - Country:US
Practice Address - Phone:317-329-2219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041993103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200285860Medicaid
IN200285860Medicaid